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Variations in rates of appropriate and inappropriate carotid endarterectomy for stroke prevention in 4 Canadian provinces

From the departments of Clinical Neurosciences (Kennedy), Community Health Sciences (Quan, Ghali) and Medicine (Kennedy, Ghali), University of Calgary, Foothills Hospital, Calgary, Alta., and the Faculty of Medicine and Dentistry, University of Alberta and Capital Health, Edmonton, Alta. (Feasby)

Correspondence to: Dr. Thomas E. Feasby, 1J2.10 Walter C. Mackenzie Health Sciences Centre, 8440-112 St., Edmonton AB T6G 2B7; fax 780 407-7161; tomfeasby{at}cha.ab.ca

Background: Carotid endarterectomy (CE), when performed on appropriate patients, reduces the incidence of stroke, yet there are marked variations in rates of this procedure. We sought to determine reasons for the variation in CE rates in 4 Canadian provinces.

Methods: We identified all CEs performed in 4 Canadian provinces between January 2000 and December 2001, inclusive. From chart review and expert assessment, we determined the proportion of these procedures that were appropriate, inappropriate or of uncertain appropriateness, using the RAND/UCLA Appropriateness Method. We sought to determine the variation in rates by province and whether the variation was due to differences in type of hospital, surgical specialty or surgical volume.

Results: Overall, 1656 (52.3%) of the 3167 CEs studied were performed for appropriate indications. The proportions of appropriate procedures were 78.2% (176/225) in Saskatchewan, 58.7% (481/819) in Alberta, 49.1% (350/713) in Manitoba and 46.0% (649/1410) in British Columbia (p < 0.001 across provinces). Rates of appropriate procedures per 100 000 population ranged from 44.3 in Manitoba to 16.2 in Saskatchewan (p < 0.001 across provinces). CEs were more likely to be appropriate when performed by a neurosurgeon compared with all other surgeons (74.4% v. 49.4% were appropriate; p < 0.001), when performed by surgeons doing fewer than 31 procedures over 2 years compared with surgeons doing more than 31 (70.1% v. 49.5% were appropriate; p < 0.001) and when performed in hospitals doing fewer than 135 procedures per year compared with hospitals doing more than 135 (63.4% v. 49.1% were appropriate; p < 0.001). Overall, 10.3% of procedures were done for inappropriate reasons.

Interpretation: Our findings suggest some overuse (for inappropriate or uncertain indications) but also some underuse (low population rates in some regions). High rates of CE are associated with lower rates of appropriateness for both surgeons and hospitals. That 1 in 10 CEs is done inappropriately suggests the need for preoperative assessment of appropriateness.

This article has been cited by other articles:

				L.-P. Girard, T. E. Feasby, M. Eliasziw, H. Quan, J. Kennedy, H. J.M. Barnett, and W. A. Ghali Complication Rates After Left- Versus Right-Sided Carotid Endarterectomy Circ Cardiovasc Qual Outcomes, November 1, 2009; 2(6): 642 - 647. [Abstract] [Full Text] [PDF]

				T. E. Feasby, J. Kennedy, H. Quan, L. Girard, and W. A. Ghali Real-World Replication of Randomized Controlled Trial Results for Carotid Endarterectomy Arch Neurol, October 1, 2007; 64(10): 1496 - 1500. [Abstract] [Full Text] [PDF]

				G. Belli and P. Presbitero Questions on the First Consensus Document of the ICCS-SPREAD Joint Committee on Carotid Artery Stenting Stroke, July 1, 2007; 38(7): e54 - e54. [Full Text] [PDF]

				T. E. Feasby and H.J.M. Barnett Improving the appropriateness of carotid endarterectomy Neurology, January 16, 2007; 68(3): 172 - 173. [Full Text] [PDF]

				E. A. Halm, S. Tuhrim, J. J. Wang, M. Rojas, E. L. Hannan, and M. R. Chassin Has evidence changed practice?: Appropriateness of carotid endarterectomy after the clinical trials Neurology, January 16, 2007; 68(3): 187 - 194. [Abstract] [Full Text] [PDF]

				T. E. Feasby Is the Canadian health care system better for neurologic care? Neurology, November 28, 2006; 67(10): 1744 - 1747. [Full Text] [PDF]

				S. Lewis Physicians, it's in your court now Can. Med. Assoc. J., August 2, 2005; 173(3): 275 - 277. [Full Text] [PDF]

				H. J.M. Barnett The inappropriate use of carotid endarterectomy Can. Med. Assoc. J., August 31, 2004; 171(5): 473 - 474. [Full Text] [PDF]

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